What are the recommended treatment guidelines for an elbow strain, including initial RICE (Rest, Ice, Compression, Elevation) care, use of non‑steroidal anti‑inflammatory drugs (NSAIDs), physical therapy progression, and criteria for imaging, corticosteroid injection, or surgical referral?

Treatment Guidelines for Elbow Strain

Begin with conservative management including rest, activity modification, ice application, NSAIDs, and physical therapy, which successfully resolves symptoms in approximately 80% of cases within 3-6 months. 1

Initial Conservative Management (First-Line Treatment)

Activity Modification and Rest

• Implement relative rest and activity modification to prevent ongoing damage while continuing non-aggravating activities. 2, 1
• Never completely immobilize the elbow, as this leads to muscle atrophy and stiffness. 1
• Avoid positions or activities that reproduce the pain, particularly repetitive strain movements. 1

Cryotherapy

• Apply ice for 10-minute periods through a wet towel to provide effective short-term pain relief. 2, 1
• This can be repeated multiple times daily during the acute phase. 2

NSAIDs for Pain Control

• Topical NSAIDs are preferred over oral NSAIDs, especially in elderly patients, to provide effective pain relief while avoiding gastrointestinal, renal, and cardiovascular risks. 1
• Oral NSAIDs provide short-term pain relief but do not alter long-term outcomes. 2
• Continue NSAIDs during the initial 0-4 week phase as needed for symptom control. 2

Physical Therapy and Rehabilitation (Weeks 4-12)

Eccentric Strengthening Exercises

• Eccentric strengthening exercises are the cornerstone of rehabilitation, promoting tendon healing and increasing strength through tensile loading that stimulates collagen production. 1
• These exercises should be initiated once acute inflammation subsides. 1

Stretching Program

• Incorporate stretching exercises for the wrist extensors and flexors into the rehabilitation phase. 1
• Progress gradually based on pain tolerance and functional improvement. 1

Additional Modalities

• Therapeutic ultrasound may decrease pain and increase collagen synthesis, though evidence for consistent benefit is weak. 1
• High-voltage galvanic stimulation may promote the healing process in some cases. 3

Imaging Criteria

Initial Imaging

• Plain radiographs of the elbow should be obtained initially to rule out fractures, heterotopic ossification, or osteoarthritis. 2, 1
• Radiographs can identify avulsion fractures at tendon attachment sites and joint effusions suggesting occult fractures. 4

Advanced Imaging Indications

• MRI elbow without IV contrast may be considered if symptoms persist or worsen despite 4-6 weeks of conservative management, to evaluate for occult soft tissue pathology, tendon degeneration, or nerve entrapment. 1
• MRI is not indicated as initial imaging for acute elbow strain. 4
• CT, bone scan, and contrast-enhanced imaging have no role in initial evaluation of elbow strain. 4

Second-Line Treatments (Persistent Symptoms at 4-12 Weeks)

Corticosteroid Injections

• Local corticosteroid injections (such as 24 mg betamethasone with 1% lidocaine) may provide short-term pain relief but should be used with caution, as they do not alter long-term outcomes and may inhibit healing. 2, 1
• Corticosteroid injections are more effective than oral NSAIDs for acute-phase pain relief but carry risks including skin atrophy, infection, and tendon weakening. 2
• Use sparingly and only after initial conservative measures have been attempted. 2, 1

Counterforce Bracing

• A counterforce brace may reduce overload forces on the affected tendons during activities. 3
• This can be particularly helpful for patients who must continue some level of activity during recovery. 3

Surgical Referral Criteria

Timing for Surgical Consultation

• Surgical evaluation is warranted only if pain persists despite 6-12 months of well-managed conservative treatment. 2, 1
• Never proceed directly to surgery without a 3-6 month conservative trial unless significant motor weakness or muscle atrophy is present. 5

Surgical Options

• Surgical intervention may include excision of abnormal tendon tissue and longitudinal tenotomies. 1
• Surgery should be reserved for carefully selected patients who have failed conservative therapy. 2

Common Pitfalls to Avoid

• Do not rely on corticosteroid injections as first-line treatment—they provide only temporary relief and do not address the underlying pathology. 2, 1
• Avoid complete immobilization, which leads to stiffness and muscle atrophy requiring prolonged rehabilitation. 1, 6
• Do not proceed to advanced imaging (MRI, CT) without first attempting conservative management for at least 4-6 weeks. 4, 1
• Recognize that longer symptom duration before treatment initiation is associated with treatment failure, emphasizing the importance of early conservative intervention. 2

Treatment Timeline Algorithm

Phase 1 (0-4 weeks): Rest, activity modification, ice application, NSAIDs (preferably topical), and padding. 2

Phase 2 (4-12 weeks): Continue conservative measures, initiate eccentric strengthening exercises and stretching program, consider therapeutic ultrasound. 2, 1

Phase 3 (3-6 months): If symptoms persist, consider corticosteroid injection for short-term relief while continuing rehabilitation. 2, 1

Phase 4 (6-12 months): If refractory to all conservative measures, obtain MRI for surgical planning and refer for surgical consultation. 2, 1